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The Benefits of Mirror Exposure Therapy in Eating Disorders Treatment

Body image disturbances are core features of several eating disorders, particularly anorexia nervosa, bulimia nervosa and often binge eating disorder. Individuals with these disorders frequently suffer from preoccupation with their shape and/or weight and disturbances in how they perceive their bodies. They place high value on attaining their ideal shape and/or weight. They may spend an excessive amount of time looking at themselves in mirrors or avoiding mirrors altogether. They may pinch themselves or weigh themselves excessively to measure themselves. They often compare themselves negatively against others (Shafran et al., 2004). Negative body image drives disordered eating in these individuals and these associated symptoms can be even more distressing to individuals with eating disorders than the disordered eating and its direct medical consequences. Negative body image isn’t limited to individuals with eating disorders: body dysmorphic disorder is an extreme form of body dissatisfaction with a specific perceived defect and, in fact, many people without psychiatric illnesses experience shame, anxiety and other negative affects due to dissatisfaction with their appearance. Individuals who overvalue their shape and/or weight are also more likely to abuse appearance and performance enhancing drugs, such as anabolic steroids and stimulants. Thus, body image disturbances can cause significant distress and impairment and are, therefore, an important target of treatment.

Mirror exposure therapy is a type of exposure therapy during which a trained therapist guides a patient looking at themselves in a mirror over several sessions with the end goal of improving body image. Mirror exposure has been used as a component of comprehensive cognitive behavioral therapy (CBT) treatment and as a stand-alone treatment modality for body image disturbances. Several versions of mirror exposure therapy have been studied. Some therapists guide their patients in describing their appearance using only emotionally neutral, objective language, starting with their head and progressing to their feet. Others guide their patients to freely observing their reflection while describing emotions as they arise. Common features of different approaches include 1) asking patients to refrain from describing themselves using subjective descriptions of their appearance and redirecting them when they do. For example, after redirection, a patient who initially described their nose as “big” might say that it is “about 2 inches long, 1 inch wide at the base and protruding at a 40-degree angle” and 2) asking patients to wear progressively more revealing clothing. Patients may also be encouraged to engage in avoided activities between sessions or to reduce their time checking themselves in mirrors outside of session. In studies of mirror exposure therapy, it is typically provided over 4 to 6 one-hour long sessions. Similar treatment courses are used in clinical practice for most individuals, but a longer course may be appropriate for patients who continue to benefit.

Mirror exposure therapy has been shown to be effective for the treatment of body image disturbances in four randomized, controlled trials. Three of these trials studied women who had body image disturbances but did not have eating disorders (Delinsky & Wilson, 2006; Glashouwer et al., 2016; Moreno-Domínguez et al., 2012). One trial studied individuals with eating disorders and had positive results when mirror exposure therapy was used adjunctively to standard of care eating disorder treatment (Hildebrandt et al., 2012). Although these trials were small and should be considered preliminary, they had positive results and together, they suggest that mirror exposure is moderately effective for the treatment of body image disturbances (Griffen et al., 2018).

While mirror exposure therapy has been shown to be effective in clinical trials, it may not be appropriate for the treatment of all individuals with body image disturbances (Griffen et al., 2018). Individuals with certain comorbid psychiatric conditions like a current major depressive, manic or psychotic episode, who are currently suicidal or who recently engaged in deliberate self-harm (e.g. cutting) might experience an exacerbation of these symptoms during mirror exposure. Those with anorexia nervosa who are underweight should wait until they have attained a healthy weight to try mirror exposure. Finally, studies of mirror exposure therapy have included very few males or individuals with BMI over 30 kg/m2. Thus, there is insufficient safety and efficacy data for these groups to consider mirror exposure therapy an evidence-based treatment for them. Clinical experience, however, suggests that they may benefit.

Mirror exposure therapy is an important, evidence-based treatment for body image disturbances and a large number of people could benefit from treatment. Individuals with eating disorders and body image disturbances should consider adjunctive mirror exposure therapy during the course of their eating disorder treatment; however, mirror exposure therapy should not be the only treatment for an eating disorder. Mirror exposure therapy can also be helpful for individuals with body dissatisfaction who do not have an eating disorder.